July 17th July 22nd, 2005





        Approximately 30 high school juniors and seniors with disabilities will be selected to attend.

        Youth Leadership Forum for Students with Disabilities will pay for the following appropriate expenses:



    accommodations for student delegates to attend including but not limited to: interpreters, alternative format materials, personal care attendants

    scholarships based on need to defray travel expenses to the forum can be provided

        Exciting, fun, educational five-day leadership training program includes: tour of the State Capitol, meeting with community leaders with disabilities, and hearing from speakers on a variety of topics.






P Complete ALL information on pages 1 through 4 of this application.

P Please type or print with black ink.

P Mail the application to the address on the last page (page 4).

P Please see Pages 5-6 for additional application information.


1. _________________________________________________ 2. Male_____ Female _____

Students Last Name First Middle

3. Student's Social Security Number ______________________________________________


4. _________________________________________________________________________

Parent/Guardian Last Name First Middle


5. ____________________________________________________________________________

Residence Address City State ZIP


6. ____________________________________________________________________________

E-mail Address- Please write legibly


7. ______________________________________ 8. __________________________________

(Area Code) Home Telephone Number Grade Level on December 31, 2004


9.Are you the direct descendent of a Veteran? _____No _____Yes If yes, give name and relationship.




10. ____________________________________________

Name of High School



11. School Mailing Address City State ZIP


12. _____________________________________ 13. ___________________________________

High School Guidance Counselors Name (Area Code) School Telephone Number


14. Birth date: __________________________ Date Graduation Expected: ______________



15. In your own words, describe your disability. (This information will assist in assuring that we include delegates with a diversity of disabilities and match with appropriate mentors.)








16. Race/Ethnicity: Native American _____Asian _____Black _____Hispanic _____

White (non-Hispanic) _____Other _____


17. Information for Division of Vocational Rehabilitation Services (DVRS), or Iowa Department for the Blind (IDB)

If you are currently a client of the Division of Vocational Rehabilitation or Department for the Blind.


DVRS/IDB Counselors Name:______________________________________________________


18. _________________________________________ _____________

State Senators Name District Number


19. _________________________________________ _____________

State Representatives Name District Number


20. Please attach a copy of your latest High School Transcripts.


21. Letters of Recommendation:

Attach two letters of recommendation, which describe your demonstrated leadership skills or your leadership potential. Each letter must have an original signature and arrive in a sealed envelope. Please submit the two sealed envelopes containing the reference letters with this application. One letter must be from a high school representative and one must be from a community representative outside of your school.






List name, position/title, organization and telephone number of the two people who write these letters.



Name Title


Organization (Area Code) Telephone Number




Name Title


Organization (Area Code) Telephone Number


22. School and Community Involvement

Briefly tell us about your involvement with your school and community (since 9th

grade). This may include any offices you have held, club memberships, after school activities or work experiences. Include the length of involvement, your grade level at the time of participation, and the name of an adult with whom you worked.


23. Tell us a little about yourself:

Your responses to the four topics listed below will be used to assess your eligibility to participate in this leadership forum. You may respond by writing your answers on paper, using email, recording your answers on tape, you may videotape yourself, or come up with other mediums to answer the four topics. Send your responses along with your completed application packet.


(a) Qualifications - Explain why you are qualified to be a delegate to this forum and why you want to attend.

(b) Positive Influences - In terms of leadership, please tell us about two people who have positively influenced your life. Why? (Families, teachers, counselors, friends, or public officials are appropriate examples.)

(c) Experiences as a Person with a Disability - Describe two important experiences you have had as a young person with a disability. (Please be specific about your examples as they relate to your disability).

(d) Future Plans - Describe your goals for the future.


24. Please use the checklist below to make certain your application packet is complete. All questions must be answered and requested letters and information provided.


Required Items


1. Application form (4 pages)


2. Two letters of recommendation (sealed envelopes)


3. Tell us about yourself (response to four topics)


4. Transcripts


5. School/Community Activity Sheet



____________________________________________ ____________________

Signature of Student Date



If selected my child has permission to participate in the Youth Leadership Forum for Students with Disabilities.


____________________________________________ ____________________

Signature of Parent/Guardian Date


If you would like to have this application packet in an alternate format, please contact (888) 219-0471.


Thank you for completing this application. Please mail it to the address below. If you have any questions, please contact:


Iowa Division of Persons with Disabilities

Attn: YLF Committee

Lucas State Office Building

Des Moines, Iowa 50319

(888) 219-0471 (V/TTY)

(515) 242-6172 (V/TTY)





1. To be eligible for the Youth Leadership Forum, students must:

(a) Have a disability (as defined by the Americans with Disabilities Act);

(b) Be in the 11th or 12th grade as of December 31, 2004. (Some grade exceptions may be made);

(c) Have demonstrated leadership potential in school and the community; and,

(d)   Reside in Iowa.


2.      Student applicants must mail the completed application packet to the Iowa Commission of Persons with Disabilities office--postmarked no later than February 18, 2005.


3.      Semi-finalists will be selected and contacted by telephone to arrange a personal interview. Interviews will take place in March and April, 2005


4.      All applicants will be notified by letter whether they are selected to attend the forum. (Letters will be mailed by the end of April, 2005.) Approximately 30 students will be selected to attend.


5.      After being selected, students will be asked to fill out a confirmation form and provide additional information.


6. All appropriate expenses will be paid by the Youth Leadership Forum management, including such expenses as lodging, food, accommodations to attend and participate, and scholarships for travel expenses when needed.




Rules and Guidelines for Students Delegates of the Youth Leadership Forum


In order to provide a fun, safe learning experience at the leadership forum, all delegates will be expected to follow the rules listed below.


Students are selected to attend this forum because of their leadership skills and potential.

Consequently, students are expected to demonstrate their leadership ability, and must:


1. Be punctual.

2.      Be at designated places and stay with your assigned group at all times. Attendance at all general sessions is mandatory. When attendance is optional at breakout sessions, delegates are expected to attend or be in their own room.

3. Maintain a respectful attitude toward peers, counselors and conference staff.

4. Respect the facilities (maintaining the condition of dormitory rooms and all other areas). Participants will have to pay for property damage they cause and for lost room keys or towels.

5. When not in assigned groups, delegates are restricted to their own assigned rooms at all times. No coed visitation is allowed.

6. Smoking and possession or use of illegal chemicals or alcohol are strictly prohibited. (Prescription or other approved medications require verification and can only be dispensed under supervision by the medical staff.)

7.      All other campus residence halls and facilities are off limits. Walk-mans, radios and electronic games may be brought to the forum and used during free time only

8.      Cell phones are permitted but must be turned off in large group and small group settings.

9.      No student delegate will use a personal vehicle . Special arrangements can be made by parents for a student to have a vehicle at the forum but keys will be held by staff.

10.  Curfew hours: All delegates will be in their own rooms by 11 p.m. unless waived by staff supervisor.

Any violations of these rules will result in students being sent home immediately at parents/guardians expense. Your application to the Youth Leadership Forum indicates your acceptance of these rules and guidelines.


AND more importantly, we emphasize that delegates are chosen to attend the forum because of their leadership potential. Remember the responsibility that goes with the honor of being selected and plan to have a great time!!